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^ INSTRUCTIONS FOR COMPLETING 'FORM "B� ~= <br /> '^ <br /> GENERA[ TNSTQUCTIONS: <br /> I One FGRM ''B^ shall be r each tank fnr all NEW PERMlTS, PERMIT CHANGES, KEM)VALS mnd/ur any <br /> nther TANK INFORMATION CHANQE ' <br /> 2 Th1s fnrm should be com�leted by e1ther the PERMIT APPLICANT or, the LOCAL AGENCY UNDERGROUND TANK <br /> INIPECTOR <br /> 3Pl�ase tyre or �rint clemrly all renuestnd informat1on <br /> - 4 Us'P � nrd 'poojnt wr1ting instrument` you are making 3 �V�ies <br /> TOP OF FORM: 'MARK ONLY ONE "ITEM" <br /> I� Mark an (X) in 1he box r�xt tn �he 1tem �hat best descr1bes the reason the funm is being cmnpleted <br /> 2 indicate" the D�� �r Faci }ity n�ne �kere thc tank 1S 1ns�alle� <br /> - ' -- ` <br /> T. TAJNK DESCRIPTION - COMPLETE ALL ITEMS ^ IF UNKNOWN ' SO SPECIFY <br /> ` <br /> A, Indicate ownera tank ID # - If th9re is a tank number that is used by the owner to identify the tank <br /> (ex <br /> Al <br /> B lnd1cate the name of the company that nBnufochured the tank (ex. ACME TANK MFG) <br /> C Ind 1cnte the year, the tank was 1nstalled (ex l987) <br /> DIndicate the tank cuparity 1n gal lons (ex. 25,000 Or 10,000 etc. ) <br /> Il. TANK CONTENTS <br /> / <br /> ' A I 11 MOTOR VEHICLE ft UEL. check box l C <br /> and omplote items B & C <br /> � 2If not MOTOR VEHICLE FUEL. check the appropriate box in se[t10n A and complete items B & D <br /> / B Check the appropriate box, <br /> ` CCheck the type of MOTOR VEHICLE FUEL (if box l is checked in A) <br /> D Pr1nt the chemical name of the hozmrdcus substance s�ored 1n the tank and the C A 3 �� (Chemical <br /> Abstract Service number), if box l is MUT checked in A, <br /> YTT. TANK CONSTRUCTION ^ MARK ONE }TEM ONLY IN BOX A, B. C & D <br /> l Check only one item in TYPE OF CYST[M, TANK MATERIAL. INTEQlOR LlNTNG and CORROSION PRUTECTlON <br /> 2 lf UTHEG. print in the space prnv1ded ` <br /> ' <br /> TV. PIPING INFORMATION <br /> l CirCle A 1f 8b0vp grnund c�rCle U 1f un��rgrnund, and cir[le bo�h 1f 6ppliCnblp <br /> 2, lf UNKNOWN c1rcle� or 1f UTHER, print in space provided <br /> 3 Ind1cote the LEAK DETECTICN system(s) used to ramply with the monitoring requ1rement fnr the pi0ng <br /> V. TANK LEAK DETECTION <br /> I, TndiCat9 the LEAK DETECTION system(s) u5�d t10 comply with the mnnitnring requirements for th6 tank, <br /> VT. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> lESTlM"FED DATE L-ST U3EO MONTH/YEAR (Januury. l888 or 01 /8 <br /> 2 E3Tl�AT[D OUANTlTY nf HAZ�RDOUS 3U8ST4NCE rema1ning in the tank (1n Gallon6), <br /> 3 WAS TANK FILLED WITH lNERT MATERIAL? Check 'Yes' 8r 'NO' <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The state underground storage tank 1dent1f1cati'mn number is. composed of the two digit cnunty number, the three <br /> d1git jurisd�c�ion number' the six digit fmc1l1ty number and the s�x, digit tank number. The county und <br /> ]urisdict1nn numbers are predetermined and can be obtained by call1 State Board (91,6) 227 43O3� 7he <br /> fac1lity num er must be �he same as shown, 1: form ''A" The tank num�e� h�v`be atsign�d ' the locol agenry. <br /> however, this number\must be mun ri.Cal and cannVt'contn1d a� �l�habet l���he local agency prefers the State <br /> BoarU to a�slgn-the tank nu�6��' please leave 1t bl�nk�� -^ ' ` ^ - <br /> IT IS THE RESPUN3JBlLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br /> INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY' INFORMATION BOX <br /> AND FOR FORWARDING ONE FORM ~A~ ANDASSOCIATED FORM ~B^(s) TO THE FOLLOWING ADDRESS, <br />